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HomeMy Public PortalAbout4803ALESSANDRO AVE_Plumbing (7) i WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A rinsure or a certificate of Workers Compensation Insurance CE 817(REV 10/81) or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING EJ !1 A-tGr Certified copy is filed with the county building ,nspec ADDRESS G:�! tion department NUMBER FIXTURE OR ITEM Q FEE LOCALITY WATER CLOSET Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST COMPENSATION INSURANCE SHOWER OWNER OOOLIA—L D F (This section need not be completed if the work involved by MAIL r the permit is for one hundred dollars ($100)or less ) LAVATORY ADDRESS 0 11245 12 I certify that in the performance of the work for which this permit is issued I shall not employ any person in any manner SINK CITY P14- TEL NO,'7e61.19/ so as to become subject to the Workers Compensation Laws DISHWASHER CONTRACTOR sLJ'rZ5,,1J!50?� �L I N Date Applicant CLOTHES WASHER J ADDRESS NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR � Exemption you should become subject to the Workers t Q Compensation provisions of the Labor Code you must forth CITY i� TEL NO�aI�.S4 LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE �y / LIC 4 `��r deemed revoked WATER HEATER LICENSE NO� L©(Q S CLASS JC-—r 41 C-"3C LICENSED CONTRACTORS DECLARATION DISTRICT NO ROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �. (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ' >, and Professions Code and my license is in full force and effect / 5 PER SYSTEM FINALCL License Number `Ya6tls L c Clasy 4 DATE �� Al VALIDATION u FIN L L 09 Contractor Date BY ❑ f I am exempt under SecCL rL B 8P C for this reason H Plan check fee Date PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE 51 Plan check applicant SINGLE FAMILY HOME OWNER BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor s License Address Law for the following reason (Section 7031 5 Business and 3 617 6 A Professions Code) City Tel No ❑ I as owner of the property will do the work and the ro a 0 0 0 5 structure is not intended or offered for sale (Section 7044 Business and Professions Code) 2'Q 0 3050 CONSTRUCTION LENDING AGENCY 0 0 0 3 0 5 0= j hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued 0 7 14-83 (Sec 3097 Civ C ) Lender s Name Lender s Address I certify that I have read this application and state that the , above information is correct I agree to comply with all County ordinances and State jaws regulating Plumbing and ereby authorize representatives of thi County to a er Ion the above mentioned property for i spection purp ses SEE REVERSE FOR EXPLANATORY LANGUAGE ature of P rmittee Date